检索结果-南通市图书馆

Impact of an educational intervention on medical records documentation

World Journal of Emergency Medicine 2018年第2期9卷 136-140页

作者： Hojat Sheikhmotahar Vahedi minasadat mirfakhrai Elnaz Vahidi Morteza Saeedi Emergency Medicine Research Center Emergency Medicine Department Shariati Hospital Tehran University of Medical Sciences Emergency Medicine Department Shariati Hospital Tehran University of Medical Sciences

BACKGROUND: Inaccurate and incomplete documentation can lead to poor treatment and medicolegal consequences. Studies indicate that teaching programs in this field can improve the documentation of medical records. The study aimed to evaluate the effect of an educational workshop on medical record documentation by emergency medicine residents in the emergency ***: An interventional study was performed on 30 residents in their first year of training emergency medicine(PGY1), in three tertiary referral hospitals of Tehran University of Medical Sciences. The essential information that should be documented in a medical record was taught in a 3-day-workshop. The medical records completed by these residents before the training workshop were randomly selected and scored(300 records), as was a random selection of the records they completed one(300 records) and six months(300 records) after the ***: Documentation of the majority of the essential items of information was improved significantly after the workshop. In particular documentation of the patients' date and time of admission, past medical and social history. Documentation of patient identity, requests for consultations by other specialties, first and final diagnoses were 100% complete and accurate up to 6 months of the ***: This study confirms that an educational workshop improves medical record documentation by physicians in training.

关键词： Medical records documentation Emergency Medicine First degree residents

来源：

维普期刊数据库

同方期刊数据库评论

在线全文

学校读者我要写书评

暂无评论

欢迎您,

建议与咨询留下您的常用邮箱和电话号码，以便我们向您反馈解决方案和替代方法

时间限定

文献类型

馆藏选择

核心期刊

语言

文献类型

帮助

文字说明：

检索规则说明：

检索范例：

分类表

所选分类

限定检索结果

文献类型

馆藏范围

日期分布

学科分类号

主题

机构

作者

语言

在线全文

请选择保存的检索档案：

请选择收藏分类：

通借通还

欢迎您,

建议与咨询 留下您的常用邮箱和电话号码，以便我们向您反馈解决方案和替代方法

时间限定

文献类型

馆藏选择

核心期刊

语言

文献类型

帮助

文字说明：

检索规则说明：

检索范例：

分类表

所选分类

限定检索结果

文献类型

馆藏范围

日期分布

学科分类号

主题

机构

作者

语言

在线全文

请选择保存的检索档案： 新增检索档案 确定 取消

请选择收藏分类： 新增自定义分类 确定 取消

通借通还

建议与咨询留下您的常用邮箱和电话号码，以便我们向您反馈解决方案和替代方法

请选择保存的检索档案：

请选择收藏分类：